BACKGROUND:Morel-Lavallee lesions are traumatic closed degloving injuries. Operative intervention remains the primary treatment approach. However, high-quality postoperative outcomes data are limited. This study aimed to determine the rate of wound complications associated with Morel-Lavallee lesions and identify risk factors for postoperative wound complications. METHODS:A prospective, multicenter, observational study (2021-2024) was conducted across 15 trauma centers. Adult patients with a Morel-Lavallee lesion who underwent operative management were included. The primary outcome was incidence of wound complications, defined as cellulitis, deep wound infection, skin necrosis, necrotizing soft tissue infection, and organized hematoma. Multivariable logistic regression was performed to identify predictors of wound complications. RESULTS:Among 134 patients who underwent operative intervention for Morel-Lavallee lesions, 27 (20.1%) developed a postoperative wound complication. Wound complications included skin necrosis (n = 10, 7.5%), deep wound infection (n = 9, 6.7%), cellulitis (n = 7, 5.2%), organized hematoma (n = 7, 5.2%), and necrotizing soft tissue infection (n = 3, 2.2%). In patients with wound complications, more frequent mechanisms of injury were bicycle collision (14.8% vs. 1.9%, P = .004) and pedestrian struck by motor vehicle (37.0% vs. 15.0%, P = .010). On multivariable analysis, only pedestrian struck by motor vehicle mechanism of injury (odds ratio 3.44, 95% CI 1.29-9.17, P = .014) was an independent predictor of increased wound complications when also controlling for closure of dead space, current tobacco use, and diabetes. CONCLUSION:More than one fifth of patients undergoing operative management of Morel-Lavallee lesions developed a postoperative wound complication. The only independent predictor of wound complications was pedestrian struck by motor vehicle mechanism of injury. These findings may help guide patient counseling.

Introduction: Foreign body-induced pancreatitis is rare and diagnostically challenging, often presenting with non-specific symptoms and no clear history, unlike typical causes. Case Report: A 70-year-old man presented with vomiting and abdominal tenderness. Imaging revealed a 4-cm sharp foreign body near the pancreatic head causing inflammation. Endoscopy and endoscopic ultrasound failed to locate the object. Surgical exploration with intraoperative ultrasound identified and removed the foreign body at the pylorus-duodenal junction. The patient recovered without complications. Conclusion: Early diagnosis, multimodal imaging, and surgical collaboration are essential for optimal management of foreign body-induced pancreatitis.

Background Costosternal cartilages and the costal margin, collectively termed costal cartilage, are hyaline cartilage connecting ribs to the sternum and to adjacent ribs, respectively. Presence of intact costal cartilage is essential for elasticity of the chest wall. Anecdotally, costal cartilage injuries are underdiagnosed on trauma CT scan in patients with rib fractures. Our aim was to determine a baseline frequency of acute costal cartilage injury among patients presenting with rib fractures.Methods We performed a retrospective cohort study of injured adult patients admitted to Level I/II trauma centers with rib fractures from January 2020 to July 2024. CT images obtained at admission were manually reviewed by chest wall surgeons for presence of costal cartilage injury. Concordance with the original radiology report was obtained. Multivariable regression was used to analyze factors associated with costal cartilage injury and missed cartilage fractures.Results 1441 patients were identified; 197 (14%) had a costal cartilage fracture. A plurality of injuries included falls (n=667, 46%). Median ISS (Injury Severity Score) was 13 (IQR: 9 to 21), median Abbreviated Injury Scale thorax score was 3 (IQR: 3 to 3), and median number of fractured ribs was 3 (IQR: 3 to 7). 294 (21%) patients had radiographic flail segments, and 136 (9%) had sternal fractures. 172 (87%) patients had a costal cartilage fracture missed on initial trauma chest CT. On multivariable analysis, ISS (adjusted OR (aOR) 1.02 (95% CI 1.01 to 1.04), radiographic flail segment (aOR 1.6 (95% CI 1.10 to 2.31)) and presence of sternal fracture (aOR 1.85 (95% CI 1.19 to 2.89)) were associated with costal cartilage fractures. Only the total number of rib fractures was associated with a missed costal cartilage fracture on univariate analysis (OR 1.17 (95% CI 1.01 to 1.36)).Conclusions Costal cartilage injuries are common and frequently are not identified during interpretation of the initial trauma CT. A higher index of suspicion is warranted for costal cartilage fractures among patients with greater injury burden, radiographic flail segment, and sternal fractures.Level of evidence Level III.

Morel-Lavallee lesions (MLLs) are traumatic closed degloving injuries with operative intervention (OI), especially excisional debridement, remaining the mainstay of treatment. However, high-quality evidence describing operative techniques and outcomes remains limited. This study aimed to characterize current OI practices and associated outcomes, especially among patients undergoing excisional debridement, hypothesizing an increased risk of wound complications with this approach for MLLs.MethodsThis prospective (2021-2024), multicenter, observational study was conducted across 15 trauma centers and included patients diagnosed with MLL who underwent OI. The association between operative technique (eg, excisional debridement) and the primary outcome of wound complications was evaluated. Wound complications were defined as cellulitis, deep wound infection, skin necrosis, necrotizing soft tissue infection (NSTI), and/or organized hematoma.ResultsOf 88 MLL patients undergoing OI, 36 (40.9%) had excisional debridement, with 4 (11.1%) limited excision to skin, 20 (55.6%) extended to subcutaneous tissue, and 12 (33.3%) down to muscle. Excisional debridement had higher rates of skin necrosis (22.2% vs. 1.9%, P = .002). Although overall rates of wound complications were statistically similar between cohorts (33.3% vs. 17.3%, P = .098), univariate analysis demonstrated excisional debridement had increased risk of wound complications (OR 2.52, CI 1.07-5.97, P = .035).ConclusionThis prospective multicenter study over three years demonstrated that a fifth of MLLs undergoing excisional debridement developed postoperative skin necrosis. Excisional debridement also had a more than two-fold increased risk of wound complications compared to other OIs. These findings underscore the importance of investigating alternative operative techniques, such as incision and drainage or minimally invasive debridement methods.

BACKGROUND:We aimed to determine the performance of postoperative computed tomography (CT) and upper gastrointestinal series (UGI) in patients who underwent surgery for a perforated peptic ulcer and to assess the yield of routine postoperative studies. METHODS:Retrospective, single-institution, chart-review study of patients who underwent a repair of a perforated gastric or duodenal ulcer between August 2004 and September 2021 at Mayo Clinic, Rochester, Minnesota. RESULTS:We identified a total of 240 patients, 28 (12%) were found to have leaks. When any of the four findings (extraluminal gas or fluid collection adjacent to the repair, worsening pneumoperitoneum, or enteral contrast extravasation) was present on postoperative CT scan (n = 116) it had sensitivity of 76% (95% CI 53%-90%), with a specificity of 90% (95% CI 84%-91%). Upper gastrointestinal series (UGI, n = 150) showed a sensitivity of 57% (95% CI 25%-84%) and a specificity of 99% (95% CI 96%-100%). UGI demonstrated higher specificity compared to CT (p < 0.01); there was no significant difference in sensitivity (p = 0.34). The findings from CT scans led to changes in management for a significantly greater number of patients compared to UGI (20% vs. 4%, p < 0.01). The diagnostic yield for leak identification was 3% for routine postoperative CT (n = 63) and 2% for routine UGI studies (n = 141). CONCLUSIONS:Postoperative CT is more likely to change management in patients who underwent repair of a perforated peptic ulcer compared to postoperative upper gastrointestinal series. The yield of routine postoperative studies is low, and their benefit is uncertain.

BACKGROUND:This study aimed to determine which surgical technique is associated with more favorable outcomes for the repair of perforated peptic ulcers. METHODS:A retrospective medical record review of patients who underwent surgery for perforated peptic ulcers at the Mayo Clinic Rochester campus between 2004 and 2021 was performed. RESULTS:The final analysis included 277 patients: 182 underwent suture closure of the perforation, 55 underwent patch-only repair, 15 underwent gastrectomy with reconstruction, 14 underwent wedge resection, and 11 underwent other techniques. No leaks were observed in patients who underwent stapled wedge resection. Among patients who underwent repair of the perforation (n = 237), 3 variables associated with the leak on univariate analysis were included in a logistic regression model. All 3 variables were independently associated with a leak: lack of suture closure of the perforation (odds ratio [OR], 7.0; 95% CI, 2.5-19.1), immunosuppression (OR, 5.5; 95% CI, 1.7-17.6), and lactate levels (OR, 1.4; 95% CI, 1.1-1.7). CONCLUSION:When both sutured and patch-only closure techniques are feasible for a perforated peptic ulcer, sutured closure is associated with a lower risk of leakage. However, given our study's retrospective, single-institution nature, the findings should be interpreted with caution.

Internal herniation through the foramen of Winslow is one of the rarest types of hernia. As signs and symptoms can be quite generalized, prompt identification can prove difficult, leading to increased morbidity and mortality. The majority of reported cases of foramen of Winslow herniation result in obstruction of either the small or large bowel requiring operative intervention. As they are so rare, there is no established treatment algorithm for foramen of Winslow hernias. We present here a unique case of cecal herniation through the foramen of Winslow resulting in biliary compression and acute cholecystitis without bowel obstruction that was managed with laparoscopic cholecystectomy and right hemicolectomy.

PURPOSE:Trocar site hernias impact 1-10% of patients undergoing a laparoscopic cholecystectomy, typically at the 10 mm port site. Risk factors identified for trocar site hernias include obesity and age; however, little is known about the impact of pre-existing diastasis rectus abdominus (DRA) on trocar site hernia rates. Therefore, we aimed to determine the impact of pre-operative DRA on trocar site hernia rates after laparoscopic cholecystectomy. METHODS:We conducted a retrospective review of patients undergoing a laparoscopic cholecystectomy for benign gallbladder disease at a single institution from January 2010 to May 2020. CT scan review was used to determine the presence of pre-operative DRA and to diagnose trocar site hernia. Logistic regression was used to determine the factors associated with development of a trocar site hernia. RESULTS:Of the 2,460 patients who underwent a laparoscopic cholecystectomy, 545 (22%) had both a pre- and post-operative CT scan and were included in analysis, with a 1.5 year median length of follow-up. Overall, 434 patients (80%) had pre-operative DRA and 88 patients (16%) developed a trocar site hernia. On logistic regression, presence of DRA was significantly associated with development of a trocar site hernia (OR = 4.12, 95% CI=[1.72,12.24], p = 0.004), while controlling for location of 10 mm port, BMI, age, sex, ASA classification, smoking status, whether surgery was elective, and presence of pre-operative umbilical hernia. CONCLUSIONS:Radiologic diagnosis of both DRA and a trocar site hernia is highly prevalent within patients who undergo a laparoscopic cholecystectomy. Further, the presence of pre-operative DRA is significantly associated with development of a trocar site hernia after laparoscopic cholecystectomy.

Intussusception following Roux-en-Y gastric bypass is a rare, potentially life-threatening complication. Patients present with intermittent obstructive symptoms, and the diagnosis is made on imaging. Treatment is surgical considering the high likelihood of non-operative failure, strangulation, incarceration, perforation and concern for malignancy. We present the case of a woman in her 60s with a history of Roux-en-Y gastric bypass who presented with retrograde jejunojejunal intussusception at the distal Roux anastomosis. She proceeded to the operating room for complete anastomotic resection with reconstruction of three blind ends via two sequential isoperistaltic anastomoses. She progressed appropriately throughout her hospitalisation and was discharged on postoperative day 5 without recurrence. While intussusception in Roux-en-Y anatomy has been previously described, a literature review yielded sparse results in detailing its surgical correction. We highlight our unique surgical approach of jejunojejunal anastomotic resection with the creation of sequential isoperistaltic side-to-side anastomoses.

BACKGROUND:Older adults presenting with trauma have worse outcomes than younger adults. Starting in 2016, we provided geriatrics consultation (GC) to older adults admitted to the trauma service. We aimed to analyze the impact of GC on patient outcomes. METHODS:We performed a retrospective pre-post study and year-matched cohort study. We identified patients from the trauma registry at our level 1 trauma center. In the pre-post study, we compared patients who received GC (2016-2022) with controls (2011-2015). In the cohort study (2016-2022), we compared patients who received GC with controls. We matched for age, race, sex, and injury severity score (ISS) in both studies, as well as admission year in the cohort study. Outcome variables included mortality (in-hospital, 30-day, 90-day), length of stay (LOS), discharge disposition, and hospital readmission rates (30-day, 90-day). RESULTS:We analyzed 1968 patients in the pre-post study and 2544 patients in the cohort study. Patients were similar in age, race, and sex. GC patients had a slightly higher ISS score and a higher rate of ICU stay. Delirium occurrence was lower among GC patients. GC patients had lower in-hospital mortality compared to controls (pre-post OR 0.27, p < 0.001; cohort OR 0.31, p < 0.001) and increased LOS (6 days vs 4 days, p < 0.001; both studies). GC patients in the cohort study also had lower 30- and 90-day mortality (OR 0.52 and 0.65, p < 0.01) and were less likely to return home (OR 0.81, p < 0.01); similar trends, though not statistically significant, were noted in the pre-post study. Lower readmission rates (statistically non-significant) were noted in the GC group across both studies. CONCLUSIONS:GC in older adults with trauma has proven benefit with reduced mortality and a trend toward lower readmission rates but was associated with increased LOS and higher rates of discharge to skilled facility.

Supplementary Figure 1. PET-CT scan images

PDF file - 73K, MDA and MHC II expression demonstrates a site cluster-specific pattern. (A) The distribution of antigen expression for each anatomic site cluster. The p-values indicate the probability that no variability exists across the site clusters as determined by the Kruskal-Wallis test.

Supplementary Table and Figures Supplementary Table 1: Differentially expressed genes between persisting and non-persisting clones. Supplementary Figure 1: % IL-7R expressing cells in the infusion bag correlates with persistence of CD8+ effector clones. Supplementary Figure 2: Representative phenotypic profiling of IL7R+ and IL7R- subsets found within infused effector clones. Supplementary Figure 3: IL-7R expression correlates with c-myc mRNA expression in CD8+ effector clones. Supplementary Figure 4: IL-7R expression correlates with induced pSTAT5 expression in CD8+ effector clones.

Supplementary Methods: Detailed information regarding additional materials and methods.

PDF file - 51K, Pairwise comparison of antigen expression by individual anatomic site cluster. Shown are p value results of Cochran-Armitage test for trend. p <0.005 considered significant (bold, underlined), p <0.05-0.005 considered a trend (bold).

Supplementary Figure 1. In situ MRI assessment of tumor melanin content. Supplementary Figure 2. UM and CM liver metastases demonstrate similar immunophenotype profile.

PDF file - 65K, TYR expression varies with the degree of CD8+ and CD4+ T cell infiltrate. (A) The distribution of antigen expression for given CD8 (blue) infiltrate score (0-3+, column). (B) The distribution of antigen expression for given CD4 (green) infiltrate score (0-3+, column).

PDF file - 47K, Individual dendrogram distance matrices for the melanoma differentiation antigens. Dendrogram distant matrices calculated from DendroUPGMA.

OBJECTIVE:To determine differences in plasma sex hormone levels in male and female coronavirus disease 2019 (COVID-19) patients and healthy volunteers (HVs) because cell entry of severe acute respiratory syndrome coronavirus 2 occurs via the angiotensin-converting enzyme 2 receptor which is downregulated by 17β-estradiol.PATIENTS AND METHODS:Citrated plasma samples were collected from 101 patients with COVID-19 upon presentation to the emergency department and from 40 HVs between November 1, 2020, and May 30, 2021. Plasma 17β-estradiol and 5α-dihydrotestosterone (DHT) levels were measured using enzyme-linked immunosorbent assay (pg/mL). Data are presented as median and quartiles (IQR). Wilcoxon rank sum test with a P value less than .05 was considered significant.RESULTS:Patients with COVID-19 (median age, 49 years) included 51 males and 50 females (25 postmenopausal). Hospital admission was required for 58.8% of male patients (n = 30) and 48.0% of female patients (n = 24) (66.7% postmenopausal, n = 16) Healthy volunteers (median age, 41 years) included 20 males and 20 females (9 postmenopausal). Female patients with COVID-19 were found to have decreased 17β-estradiol levels (18.5 [IQR, 10.5-32.3] pg/mL; 41.4 [IQR, 15.5-111.0] pg/mL, P=.025), and lower 17β-estradiol to DHT ratios (0.073 [IQR, 0.052-0.159] pg/mL; 0.207 [IQR, 0.104-0.538] pg/mL, P=.015) than female HVs. Male patients with COVID-19 were found to have decreased DHT levels (302.8 [IQR, 249.9-470.8] pg/mL; 457.2 [IQR, 368.7-844.3] pg/mL, P=.005), compared with male HVs. Levels of DHT did not differ between female patients with COVID-19 and female HVs, whereas 17β-estradiol levels did not differ between male patients with COVID-19 and male HVs.CONCLUSION:Sex hormone levels differ between patients with COVID-19 and HVs, with sex-specific patterns of hypogonadism in males and females. These alterations may be associated with disease development and severity.

PDF file - 57K, Pairwise comparison of antigen expression by individual anatomic site. Shown are p value results of Cochran-Armitage test for trend. p <0.005 considered significant (bold, underlined), p <0.05-0.005 considered a trend (bold).